Scott Villa

Maintain facility in clean, safe, sanitary condition

Based on observation, the licensee did not comply with the section cited above in paint of bathroom vanities/cabinets in 2 residents rooms heavily chipped which pose a potential personal rights risk to persons in care.

§1569.269 Enumerated rights; severability: (a)Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency.... ....to meet their needs.-This requirement is not met as evidence by:-Based on interviews and records review, the licensee did not comply with the section when R1 sustained injuries which posed an immediate health, safety and/or personal rights risks to person in care.

CONTINUATION:-Based on records review, interview and observation, the licensee did not comply with the section above in not documenting on LIC622 the medications of R1 that were to be disposed.

Dispose of unused medications with required witness

87465 Incidental Medical and Dental Care (i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record ... shall be destroyed in the facility by the facility administrator and one other adult who is not a resident.....-This requirement is not met as evidenced by:

Maintain facility in clean, safe, sanitary condition

87303 Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. -This requirement is not met as evidenced by:-Based on observation, the licensee did not comply with the section above in extra hospital bed, detached baseboard and wall moulding with protruding nail in the resident's room which pose a potential risks to persons in care. This is a repeat violation.

87211 Reporting Requirements(a)(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified (A)Death of any resident from any cause regardless of where the death occurred.... -This requirement is not met as evidenced by:-Based on record review and interview, the licensee did not comply with the section above in not sending the Death Report for resident (R1) which posed a potential personal rights risk to person in care.

Auditory exit monitoring for elopement risk

87705 Care of Persons with Dementia(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates .........-This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above in auditory signal not in working conditon which poses an immediate safety risk to persons in care.

87211Reporting Requirements (b) Any suspected physical abuse that results in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within two (2) hours.......-This requirement is not met as evidenced by: -Based on records review and interview, the licensee did not comply with the section in not reporting to the agencies includin the Department the suspected abuse which posed an immediate safety and/or personal rights risks to person in care.

Maintain facility in clean, safe, sanitary condition

Based on observation, the licensee did not comply with the section cited above iin missing drawers and drawer knob in R5's room which poses a potential personal rights risk to persons in care.

§1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.-This requirement is not met as evidenced by: -Based on interviews and review of video footage, the licensee did not comply with the section above when staff yelled at resident which posed a potential personal rights risk to person in care.

Notify agency before locking doors or gates

Based on observation, the licensee did not comply with the section cited above in razor in R5's ensuite toilet which poses an immediate safety risk to persons in care.

Maintain separate complete record for each resident

Based on record review, the licensee did not comply with the section cited above in quantity of all of R1's 9 medications received by the facility does not match the quantity listed on LIC622 which poses/posed a potential health and/or personal rights risk to person in care.

Based on observation, the licensee did not comply with the section cited above. LPA observeda protruding pipe about 8 1/2 inches high from the ground in the front yard which a potential safety risk to persons in care.

Resident access to hazardous items with safety review

Based on observation. the licensee did not comply with the section cited above for staff's medication in unlocked cabinet in unlocked kitchen which poses an immediate health and safety risks to persons in care.

Based on observation and interview, the licensee did not comply with the section cited above for all sliding doors without alarm and instead has a latch in one of them which pose a potential personal rights risk to persons in care.

Ensure hazardous items are locked and not unattended

Based on observation, the licensee did not comply with the section cited above in having the Lysol and Glade spray and shaving cream unlocked and readily accessible to residents which pose an immediate health and safety risks to persons in care.

Maintain separate complete record for each resident

87506 Resident Records(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available......-This requirement is not met as evidenced by: -Based on records review, the licensee did not comply with the section above for not having R1's documents properly filled up which poses personal rights risk to person in care,

Safe, healthful, comfortable accommodations

Based on observation the licensee did not comply with the section cited above in using two entrance doors for staffs , Administrator told LPAs that staffs are using two entry ways one in the front and one at the back & kitchen staff is not wearing mask which poses/posed a potential health, safety risk to persons in care.

Clean linen quantity and hygiene supplies

Based on observation the licensee did not comply with the section cited above in 2 Shared bathrooms ensuite bathroom have no paper towel for drying hands . One of this bathrooms have common hand towel which poses/posed a potential health, safety to persons in care.